Richard North, 31/03/2020  
 


I wonder if Peter Hitchens and his supporters would dismiss this as a fantasy got up by the Daily Mail, or claim that it represents just a typical week in the life of an NHS doctor.

But then, we could simply accept that the 22,141 reported cases of Covid-19 are nothing different than one might expect from a normal winter flu outbreak, in which case the "lockdown" policy is indeed "grotesque, absurd and very dangerous".

As for the 1,408 dead, they are apparently just a reporting artefact arising from the failure of doctors to understand reporting guidelines, thus mistakenly pronouncing Covid-19 as the underlying cause of death when it should merely have been noted as a contributory cause.

We must also believe that physicians throughout the world – even in relatively sophisticated regimes such as that prevailing in Northern Italy – are repeatedly failing to conform with the WHO recommendations in the International Statistical Classification of Diseases and Related Health Problems (ICD), and the standard coding for Covid-19.

It must also be accepted that the medical profession is routinely ignoring the long-established WHO Instructions on recording causes of death, even though they have been in place since 1979.

Thus, having discounted so many erroneous reports, and completely ignored multiple suggestions that the true death rate is being substantially under-reported, we can rest easily in our beds in the knowledge that Peter Hitchens is the one true voice of sanity.

Clearly, we must regard this epidemic as nothing more than a minor perturbation. The disruption and costs of taking action quite obviously outweigh the minor inconvenience of geriatrics dying earlier than they might otherwise have done, especially those who have died with coronavirus and not of it, after all those doctors have bungled the certification.

On the other hand, it might just be possible that what we are seeing is a real epidemic of a dangerous disease which has caught out most of the nations in the world, including the United Kingdom which is showing itself to be demonstrably unprepared for dealing with a crisis of this nature.

If this seems to be a more plausible interpretation of current events, then we can forego the wisdom of Mr Hitchens and devote ourselves to an analysis of what went wrong, and what must be done to fix it.

That other countries might have been similarly unprepared is of no real comfort to us here in the UK. Each country has its own system and its crosses to bear, and what applies to other countries might not necessarily have any relevance to our situation.

However, it is germane to note that it isn't only the Lancet that is raising a hue and cry over the government's failures. The British Medical Journal has joined in, with a long editorial declaring that: "Testing and tracing must resume urgently".

On 24 February, it says, there were nine confirmed cases of Covid-19 in the UK. On the same day, the World Health Organization recommended countries outside China with imported cases or outbreaks "prioritize active, exhaustive case finding and immediate testing and isolation, painstaking contact tracing and rigorous quarantine of close contacts".

On 22 March - when there were 5,683 confirmed UK cases - Michael Ryan, executive director of the WHO health emergencies programme, repeated the message on the BBC: "What we really need to focus on is finding those who are sick, those who have the virus, and isolate them, find their contacts and isolate them".

Says the BMJ, echoing exactly the message I have repeatedly published on this blog: "This is entirely unexceptional. Case finding, contact tracing and testing, and strict quarantine are the classic tools in public health to control infectious diseases".

This really cannot be emphasised enough or repeated too many times. We are not talking about some arcane or disputed procedure, but the very basic nuts and bolts of outbreak management.

The WHO, we are told by the BMJ, says the recommendations "have been painstakingly adopted in China, with a high percentage of identified close contacts completing medical observation". In Singapore, Vietnam, and South Korea meticulous contact tracing combined with clinical observation plus testing were vital in containing the disease.

This combined with strong measures to enforce isolation for travellers returning from high incidence areas obviated the need for a national lockdown and closure of all schools in Taiwan and Singapore.

Furthermore, the mathematical model used by the UK government clearly shows that rigorous contact tracing and case finding is effective: the prediction of 250,000 deaths was predicated on what would happen without contact tracing.

Despite this, contact tracing started in the UK but stopped early in the epidemic. How effective it was is questionable, especially in England and Wales, which made Covid-19 a notifiable disease only on 5 March, two weeks after Scotland and a week after Northern Ireland. This, coupled with the lack of surveillance and testing of those contacting primary care, says the BMJ, suggests the number of confirmed cases is an underestimate.

It then declares that the reasons why tracing was stopped, against WHO recommendations, have not been published. They seem, it says, "to be connected to a shift from 'contain' to 'delay' in the government’s action plan, when contact tracing was replaced rather than supplemented with other control measures".

One reason, it advances, seems to be a lack of tests and testing facilities. However, it says, testing is a support not a substitute for tracing or medical observation, which is crucial.

Current tests for the virus require careful validation and have low sensitivity, resulting in many false negative results, especially in the pre-symptomatic phase when viral load is low. As many as 40-50 percent of patients tested negative initially in China, and so the definition of confirmed cases was changed to include those with clinical symptoms.

But it then goes on to say that another factor is the decision to treat the situation as a single national epidemic rather than scores of local outbreaks each at different stages, needing to be tackled locally.

National figures conceal huge variation in confirmed cases, ranging from over 400 in Birmingham and Hampshire to fewer than 20 in Blackpool, Hartlepool, Darlington, and Rutland. In Scotland the first case was identified on 1 March, and Orkney and the Western Isles still have no cases.

In the much less severe H1N1 flu pandemic in 2009, this same approach "seriously impaired the ability of local agencies to respond in a flexible, timely and pragmatic way to the rapidly emerging situation".

Matters have worsened since 2009. Central control in England was entrenched by the 2012 Health and Social Care Act, which created Public Health England (PHE) to protect the health of the public in England and gave local authorities the duty to improve the health of their local populations.

PHE is legally in charge of communicable disease control and sits outside the NHS and local government in its regional hubs and field epidemiological services. Directors of public health in local authorities have little scope for proactively taking local control.

These changes are exacerbated by the decimation of public health and laboratory facilities for testing. The decrease in numbers of consultants in communicable disease control and community control teams, together with swingeing local authority cuts since 2010, have reduced the chances of a strong local response.

Local pathology and virology services have been centralised and partly privatised, leading to a fragmented mix of for-profit and public laboratories and serious staff shortages.

The scientific evidence has been dominated by behavioural science and mathematical modelling, with communicable disease control and public health sidelined. This leads to a lack of scientific challenge, as in the 2009 flu epidemic.

This very much tallies with the comments of Gabriel Scally, a former regional director of public health. He reinforces the theme of this blog that the public health service in England and Wales has been seriously depleted.

The result, he says, is the absence of any integrational, coordinating or management function at a regional level in England that could operate between Whitehall departments and the various bodies, often very local, that are charged with implementing government policy.

But it goes further than that, a situation to which Pete alludes, where the fundamental structures of government have been forgotten. This is the "invisible government" which I discussed back in 2008, the vital systems that keep society functioning, mostly without people realising they exist.

Predictably, the BMJ is urging that WHO's mantra of "trace, test, and treat" must be followed. It is not too late, it says, to adopt WHO Guidance. A second and third wave of the epidemic is likely. Contact tracing must recommence.

This, it says, means immediately instituting a massive, centrally coordinated, locally based programme of case finding, tracing, clinical observation, and testing. It requires large teams of people, including volunteers, using tried and tested methods updated with social media and mobile phones and adapting the manuals and guidance published by China.

Sadly, it ain't that simple. Having done the job in the field, I can attest that contact tracing is not an easy job. It requires training, skill and experience – and local knowledge, which can shave hours off the process of actually finding people.

This is a job that could and should be done by local authority environmental health departments which, if pushed, could put 10,000 trained professionals into the field. It is a measure of how far the system has deteriorated that these departments were not engaged from the very first.

Sadly, the BMJ concludes that the structure and capacity of our depleted healthcare system is now largely driving the response to this epidemic. It will, it says, continue to do so until services that support local communicable disease control are rebuilt and reintegrated.

And that is the truth. The blue light brigade may have the glamour and the happy-clappy support of the nation, but attention to the routine nuts and bolts of public health could have made all the difference.






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